Faces of Neurosurgery’s Founders: Victor Horsley

krisGuest post from Kristopher T. Kimmell, MD
Neurosurgical Resident, University of Rochester Medical Center
Rochester, NY 

“There has to be this pioneer, the individual who has the courage, the ambition to overcome the obstacles that always develop when one tries to do something worthwhile, especially when it is new and different.”

-     Alfred P. Sloan

The pioneer is frequently characterized by a number of strong personal traits: courageous, ambitious, visionary and irascible in the face of conventional wisdom. To forge a new path often requires tremendous diligence and patience against criticism, setbacks and failures. Indeed to forge a new field as audacious as neurological surgery requires a unique personality. Victor Horsley represents such a force of character that pioneered our specialty in its infancy. To this end, in honor of Neurosurgery Awareness Month, we are spotlighting him in our Faces of Neurosurgery’s Founders series.

Sir Victor Horsley

Sir Victor Horsley

Victor Horsley was not the first surgeon to perform a neurosurgical procedure. The practice of trephination — also known as making a burr hole, a surgical intervention where a hole is drilled into the skull — had been used for centuries. In the modern era, some general surgeons in England, particularly Sir William Macewen in Glasgow, had attempted some cranial procedures. The practice was still controversial and considered by some to be unethical. However, in 1886, at the young age of 29, Victor Horsley was the first appointed “brain surgeon” when he accepted his position at Queen Square in London, at what would become the National Hospital for Neurology and Neurosurgery. Based on the efforts of men such as Horsley, Queen Square would become one of the leading centers in the world in the study of neurologic diseases.

Despite his relative youth, at the age of 29 Horsley already had demonstrated his rare brilliance and energy. He had been appointed to the Fellowship of the Royal Society at the age of 27. Since his time in medical school at University College of London, he had conducted an extensive range of experiments elucidating the understanding of the nervous system. He used electric stimulation to localize functional areas of the brain in animals. He would eventually use this technique during surgical procedures in patients to identify so-called ‘eloquent’ regions of the human brain. Horsley was a true ‘physician-scientist’ who was very accomplished in the fields of anatomy and physiology. While at Queen Square he also oversaw the Brown Institute, which was the University College Hospital’s animal experiment laboratory.

Horsley’s surgical career was equally prolific. Shortly after his appointment to Queen Square, he operated on a man with intractable epilepsy from a traumatic injury. The operation was a great success. By the end of 1886, he had performed ten cranial procedures with only one death. By the turn of the century he had accumulated a series of 44 cranial procedures for tumors with a mortality rate of 10 percent; other practitioners in Europe had death rates near 50 percent. Horsley combined alacrity in the operating theater with delicate handling of nervous system structures to foster his success; this was a result of his tremendous knowledge and grasp of neuroanatomy from his years of experimental studies.

Sir Victor Horsley in the operating theatre, National Hospital, Queen Square, London.

Sir Victor Horsley in the operating theatre, National Hospital, Queen Square, London.

Horsley would pioneer a number surgical techniques and adjuncts during his tenure. In addition to performing the first surgeries for epilepsy, he was the first to develop a cranial approach to tumors of the pituitary gland. He was the first to perform surgery on a tumor of the spinal cord, with the patient making a marked recovery from paralysis. Horsley’s spinal surgeries were made easier by the use of instruments known as rongeurs, which were designed to remove safely hard bone immediately surrounding the spinal cord. The Horsley bone cutter, which bears his name, is still used by surgeons today. Horsley also invented a substance to abate bleeding from channels inside the bone. This mixture of beeswax, almond oil and salicylic acid is still used today and is known as bone wax. Horsley would also pioneer surgical treatments for trigeminal neuralgia or tic douloureux, a syndrome characterized by debilitating facial pain. He was the first to describe ligation of the carotid artery in the neck for the treatment of subarachnoid hemorrhage caused by a cerebral aneurysm. He also developed, with the help of Robert Henry Clark, a device that accurately localized regions inside the skull of monkeys. The so-called Horsley-Clark apparatus was one of the first attempts at stereotaxy and laid the groundwork for one of the most significant innovations in neurological surgery in the 20th Century.

In 1900, when Harvey Cushing, the father of neurological surgery in the United States, traveled to Europe to study with some of the giants of medicine and surgery, his first stop was to London to see Horsley. Despite the vast differences in their personalities and surgical styles, Cushing acknowledged Horsley as the true forebear of neurosurgery as a specialty.

Beyond his scientific and surgical exploits, Horsley was a visionary medical and social reformer. He was an avid supporter of women’s right to vote in England. He also spearheaded the reform of several medical organizations in England. Horseley had ambitions for political office when his medical career was over. However, at the start of World War I in Europe, Horsley left his practice to serve in medical corps of the British Army. He would eventually be stationed in modern-day Iraq, where he died of heat exhaustion at the young age of 59.

Neurosurgery is now a well-accepted and respected surgical specialty. A century of advances has made the range of disease processes treated by neurosurgeons vast, with ever decreasing morbidity and mortality. For today’s neurosurgeons, it’s hard to fathom that neurosurgery would not even exist without the prodigious and courageous careers of men like Victor Horsley. In honor of Neurosurgery Awareness Month we acknowledge this founder of neurosurgery and his indefatigable nature and pioneering spirit.

 

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We’ve Said It Before; We’ll Say It Again: Neurosurgeons are NOT Just Brain Surgeons

For today’s post, we are going “Throwback Thursday” style to once again underscore that neurosurgeons are NOT just brain surgeons. Since August is Neurosurgery Awareness Month, we wanted to take a moment to highlight the breadth of neurosurgical practice. Featured below is an animation demonstrating that neurosurgery is indeed more than just brain surgery! We encourage everyone to join the conversation online by using the hashtag #neurosurgerymonth.

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Faces of Neurosurgery’s Founders: Harvey Cushing

krisGuest post from Kristopher T. Kimmell, MD
Neurosurgical Resident, University of Rochester Medical Center
Rochester, NY

Did you know that August is AANS Neurosurgery Awareness Month?

This year, for Neurosurgery Awareness Month, the American Association of Neurological Surgeons is bringing attention to the role of neurosurgeons in the treatment of stroke. Materials include a review of current apps designed to support stroke diagnosis and treatment, a look at pioneers in the treatment of cerebrovascular disease and several inspiring patient stories. In addition to the AANS effort, Neurosurgery Blog will publish various items during August to promote Neurosurgery Awareness Month, including videos that highlight the tremendous accomplishments of neurosurgery’s founding fathers. As the founder of modern neurosurgery, no one is more responsible for the specialty of neurosurgery than Harvey Cushing.

Harvey Cushing, MD

Harvey Cushing, MD

Harvey Williams Cushing, MD, was born in Cleveland, Ohio, in 1869. He had a rich cultural and educational heritage, having descended from Puritans on both sides of his family as well as being a fourth generation physician in his family. After undergraduate training at Yale University, Cushing attended Harvard Medical School. Upon finishing medical school, he went to Johns Hopkins Hospital, where he came under the influence of two giants of early modern medicine. William Halsted, whose seven principles of surgery are the bedrock of modern surgical technique, was Cushing’s surgical mentor, and from him, Cushing would learn the meticulous tissue handling that was one of the hallmarks of his career. Sir William Osler was also a tremendous influence on him, and Cushing wrote a biography of Osler, for which he received a Pulitzer Prize in 1926.

Early in his career, Cushing spent time in Europe under the tutelage of two influential European physicians, Sir Charles Sherrington in England and Emil Kocher in Switzerland. It was in Switzerland where Cushing conducted experiments describing the so-called “Cushing reflex” — a physiologic triad of hypertension, bradycardia and irregular breathing associated with increased intracranial pressure. Cushing’s advances in the understanding of intracranial pressure would impact his clinical practice. He developed a palliative surgical technique known as subtemporal decompression, by which a small portion of the skull is removed to allow brain swelling through the aperture in cases of severe raised intracranial pressure as in traumatic head injuries and brain tumors. He left his practice to serve in the American Expeditionary Force as a surgeon during World War I. During his time at battlefield hospitals, Cushing advanced the practice of management of head injuries including the closure of complex head wounds.

Cushing at the Bedside of a Child

Cushing at the Bedside of a Child

Using his tremendous understanding of the nervous system coupled with his meticulous surgical technique, Cushing developed a neurosurgical practice that raised neurosurgery from a crude, barbaric practice to a refined specialty with acceptable morbidity and mortality. By the 1920s he had decreased the mortality of cranial procedures from near 100 percent to a respectable 11 percent. During his career, Cushing would operate on over two thousand brain tumors. His volume and results were more than enough to earn the praise of his colleagues, but his reputation was enhanced by his successful operation on a high profile patient. General Leonard Wood, was a high-ranking military officer who served as governor of Cuba and the Philippines and was a close friend and advisor of President Theodore Roosevelt. Wood was diagnosed with a benign meningioma in 1910 and shortly after that, Cushing successfully removed the tumor.

Cushing’s contributions to modern medicine, neuroscience, and, especially to neurosurgery, are countless. He developed the anesthesia chart, by which patient’s vital signs — including heart rate, blood pressure and respiratory rate — are routinely monitored and documented during surgery. He was the first to use the electrocautery device invented by W. T. Bovie and for whom the instrument is still named. Before the utilization of the electrocautery, Cushing developed silver hemostatic clips to limit blood loss during cranial surgery. Cushing was also a pioneer in the understanding of diseases of the pituitary gland, in particular, tumors of the pituitary. Cushing’s disease, which bears his name, is a characterized by excess cortisol caused by a hormonally active tumor of the pituitary gland. In keeping with his meticulous nature, Cushing kept specimens from many of his brain tumor patients. His vision was to have all of these specimens cataloged and available for future analysis, a sort of registry of brain tumors. This vision anticipated modern tumor and tissue banking efforts. Today many of Cushing’s brain tumor specimens, as well as his extensive medical text library (he was an avid bibliophile and collector), are on display at the Cushing Center at Yale University.

Neurosurgery today owes a great deal of its success and reputation to the herculean efforts of forebears such as Dr. Cushing. Today we honor him as one the Faces of Neurosurgery’s Founders.

 

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